Supraorbital neuralgia is one of the rare types of neuralgias where there is persistent pain in the supraorbital region and forehead with occasional sudden shocklike paresthesia in the distribution of the supraorbital nerve. The primary treatment is identification and removal of anything causing compression over the supraorbital nerve. A brief trial of simple analgesics alone or in combination with gabapentin should be considered for patients who do not respond to the above-mentioned treatments. Supraorbital nerve block using local anesthetics and steroids is the next step.

Supraorbital neuralgia is a rare type of neuralgia characterized by persistent pain over the supraorbital region and forehead along with shocklike paresthesia in the distribution of the supraorbital nerve. It is also known as goggle headache [1],[2] or swimmer's headache. [3],[4] It can also be caused after plastic reconstruction of the eyelid and eyebrow due to damage to the supraorbital nerve. [5] The supraorbital nerve is formed from the fibers of the frontal nerve, which is the largest branch of the ophthalmic nerve. The frontal nerve enters the orbit via the superior orbital fissure as it passes anteriorly beneath the periosteum of the roof of the orbit. The frontal nerve gives off a larger branch, the supraorbital nerve and a smaller medial branch, the supratrochlear nerve. Both exit the orbit anteriorly. The supraorbital nerve sends fibers to the vertex of the scalp and provides sensory innervations to the forehead, upper eyelid, and anterior scalp. In supraorbital nerve block, the supraorbital nerve is blocked which helps in the diagnosis and treatment of supraorbital neuralgia.

Supraorbital neuralgia is another possible cause of severe headaches.

It is due to damage to the supraorbital nerve just above (supra: above) the eye (orbit: the eye socket).

People who report with this pain may have a history of a blow to the head, or even a previous black eye. Original reports from the 198 state that two neurologists developed pain after swimming with ill-fitting goggles; the term 'goggle headache' was applied since then. It is a form of exertional headache that has an explosive onset with exercise, including sexual activity. The syndrome is quite rare. A tight-fitting motorcycle helmet can cause such a headache. The examination should always include pressing around the margins of the eye socket; usually, the tender supraorbital nerve is found over the inner third of the upper rim of the eye socket. Usually, the treatment is to remove the provoking stimulus like better fitting helmet or goggles or avoid repeated trauma to the affected site.

Case Report

A 38-year-old lady presented with unilateral headache and persistent pain over the left eyebrow since a year, with occasional tingling and numbness over the left eyebrow since six months. The pain was frequent and described as shooting in nature.

Pain on the visual analogue scale (VAS) was 6 out of 10. She gave a history of being hit hard by her husband on the left forehead, after which she started getting pain on the left eyebrow; there was also a history of repeat assault to this area.

On examination, vital signs of the patient were within normal limits. Examination of all other systems was normal. Neurological and ophthalmic examination was normal. Local examination showed tenderness over the left eyebrow and altered sensation over distribution of the supraorbital nerve.

Laboratory screening tests were within normal limits.

Radiography revealed no abnormality and magnetic resonance imaging (MRI) of the brain was normal. Although the patient was referred as a case of trigeminal neuralgia, it did not appear to be classical trigeminal neuralgia as there were no trigger areas, no ticlike movements over the face, and no provocation by light touch. We ruled out sinusitis, [6] as she had received antibiotics, analgesics, gabapentin, and carbamazepine with no relief. [7],[8] Hence, we decided to perform diagnostic as well as therapeutic block of the supraorbital nerve.

Procedure for supraorbital nerve block

The patient is placed in a supine position. The supraorbital notch is identified by palpation over the eyebrow. The skin overlying the eyebrow is prepared with antiseptic solution, with care being taken to avoid spillage into the eye. A 27 g needle is advanced medially approximately 15° off the perpendicular, to avoid entering the foramen and is inserted at the level of the supraorbital notch, taking care to avoid spillage into the eye. The needle is advanced until it reaches the periosteum of the underlying bone. 5 ml of injectate containing 0.5% bupivacaine 3 mL and 80 mg of triamcinolone acetate. After gentle aspiration, 3.5 mL solution is injected in fanlike distribution. During the procedure, a gauze sponge is used to apply pressure over the upper eyelid and supraorbital tissue as the loose areolar tissue of eyelid may allow the injectate to spread inferiorly into the tissue. This pressure is maintained after the procedure to avoid periorbital hematoma and ecchymosis.

Immediately after the block, the patient did not have any pain. At a follow-up after one month, she reported mild pain (3 out of 10 on the VAS scale) for which she was given a repeat block using local anesthetic and injection triamcinolone acetate 40 mg. [Figure 1] the shows course of the nerve and technique of the block.

Due to similarity of presentation as trigeminal neuralgia, frontal sinus headache, or chronic paroxysmal hemicrania, it is important to investigate the patient thoroughly. A detailed neurological examination is needed to rule out unsuspected intracranial pathology. An ophthalmological examination is needed to rule out glaucoma which may also cause intermittent ocular pain and may cause permanent loss of vision if untreated. Correct diagnosis of supraorbital neuralgia is critical in choosing the therapy. In some people, the supraorbital nerve is in the supraorbital notch and in others, it runs through a small supraorbital foramen which offers more protection at the brow of the forehead; those with the supraorbital nerve in the supraorbital notch are more at a risk for neuralgia. The treatment usually starts with avoiding the cause (ill-fitting goggles, tight helmet, repeated trauma to the area) and anticonvulsants like gabapentin, pregabalin, and carbamazepine. Stimulation of supraorbital nerve can be of help in mild cases. Other options in mild cases are acupuncture and botulinum toxin. Supraorbital nerve block definitely acts as a diagnostic and therapeutic block but using steroids may provide short-term relief; if long-term relief is needed, then endoscopic supraorbital nerve neurolysis or chemical neurolysis by using phenol/alcohol or radiofrequency ablation of the nerve are the options. [9],[10] Surgically, microvascular decompression is the treatment if the cause is vascular compression. As the forehead and scalp are highly vascular, increased incidence of postblock ecchymosis and hematoma are the frequently encountered complications. These complications can be avoided to the area of the block and application of cold packs for a period of 20 minutes after the block also decreases the amount of postprocedural pain and bleeding. Post-traumatic supraorbital neuralgia is a frequent condition although it is underdiagnosed; it has its own characteristic clinical and developmental features that distinguish it from idiopathic supraorbital neuralgia. Progress is usually good and it responds favorably to symptomatic treatment. In the modern high technological era of radiofrequency machines, there are limitations because of cost of the equipment and unavailability. Using steroids can be of help but the only limitation of its use is repeated blocks.